Failure to Maintain Required Resident Medical Records After Ownership Change
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident medical records for the required retention period, specifically for one resident whose admission MDS was submitted and accepted in early April 2022. The MDS documented that this resident had moderate cognitive impairment with a BIMS score of 11, exhibited verbal and other behavioral symptoms, and had multiple active diagnoses including hypertension, diabetes mellitus, end-stage renal disease, hyperlipidemia, seizure disorder or epilepsy, anxiety, depression, and bipolar disorder. When surveyors requested the resident’s facesheet, diagnoses list, physician orders, MAR/TAR for the full stay, progress notes, completed MDS, care plan, census list, and self-reports or investigations, the facility responded that the resident was not in the facility after March 1, 2025, and that they were unable to provide any records for this resident. Interviews with the Medical Records Director, Clinical Resource, RN Unit Manager, and DON confirmed that the facility did not have access to any paper or electronic records for this resident, or for any residents prior to March 1, 2025, unless they remained in the facility on or after that date. Staff stated that medical records were expected to be maintained for 10 years and described the contents of a complete medical record, but reported that they could not access prior records because the previous owner had stopped paying for the EMR system and no one could figure out how to access it. The facility also reported they could not provide a list of self-reports from 2022 for the same reason. Review of facility policies showed that the “Medical Record, Content of” policy required a separate medical record for each resident with specific identification data, and the “Record Retention Schedule” policy required resident medical records to be retained for 10 years and investigations for 5 years, which was not met in this case.
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